The deviated nose

What repeats

Four findings that hold across the literature.

The cause is usually how the face grew, not a blow to the nose

In 76 primary rhinoplasty patients, 9 percent reported any previous nasal trauma, while 68 percent had deviated nasal bones, 46 percent had deviated tips, 70 percent had asymmetric midfaces and 36 percent had deviated chins. Where there was no trauma history, the nasal bones deviated towards the underdeveloped side of the midface in 53 percent of cases, and the tip deviated to the side opposite the septum in 59 percent.

Rests on: Scott and Pearlman, deviation and facial asymmetry · and nasal analysis.

The shape is classified before it is operated on

Deviations are named by the axis they follow on the front view: straight to one side, called I-shaped; curved one way, called C-shaped; curved the other way, reverse C; and curved twice, called S-shaped. In one series of 169 rhinoplasties for deviation, the I-shape ran at 61.9 percent and the C-shape at 38.1 percent in one arm, and 69.4 percent against 30.6 percent in the other. The septum is classified alongside the outside shape, because an unrecognised septal deviation is the leading reason a correction fails.

Rests on: Tremp et al., septal classification · Lee and Jang, series breakdown · and septoplasty.

Straighter is the promise, straight is not

The surgeons who write most on this deformity state the limit plainly: these noses can be improved and are rarely made flawless, because each part of the nose is asymmetric and it sits on an asymmetric face. Preservation techniques were built for symmetric noses, so a deviated nose usually needs a mix of preservation and structural work.

Rests on: Kosins et al., the asymmetric crooked nose · East, preservation and the crooked nose · and preservation rhinoplasty.

Reported revision rates for severe deviation run around one in twenty

The largest single-surgeon record is 2301 extracorporeal septoplasties over twenty-five years, with follow-up revision rates of 5 percent and 7 percent. That is the number to hold against any other technique, and it comes from the surgeon who developed the method.

Rests on: Gubisch, twenty-five years · and extracorporeal septoplasty.

By where the nose is bent

The correction follows the level of the deviation.

The bones

Osteotomies cut the nasal bones free so they can be reset on the midline, and an asymmetric wedge of bone is taken from one side when one side is longer. In 78 twisted noses treated by a unilateral or asymmetric bony wedge with a let-down, most were C-shaped and 28 were I-shaped, the angle correction was significant for both, and the improvement ratio was 81 percent for C-shaped and 79 percent for I-shaped noses. A preservation variant that keeps and mobilises the bony cap was reported in 25 patients.

Rests on: Jasso-Ramirez et al., twisted nose · Yorgun et al., mobile bony cap · and component dorsal hump reduction.

The middle third

Spreader grafts and spreader flaps straighten the cartilaginous middle and hold it straight. In 35 patients, bilateral grafts corrected major deviations better than unilateral, at 179.62 degrees against 170.5 degrees, while minor deviations were corrected equally by either. A randomised study of 264 primary rhinoplasties found the spreader flap combined with a spreader graft held an angle close to 180 degrees at long-term follow-up, better than either alone.

Rests on: Gimeno-Torres et al., unilateral versus bilateral · Barone et al., spreader flaps and grafts · and spreader grafts.

The front edge of the septum

A caudal septum off the midline pushes the base of the nose and the tip with it. The graduated approach ends, where standard moves fail, in cutting the caudal septum free at the nasal spine and suturing it back on the midline.

Rests on: Constantine et al., caudal septal deviation · and the caudal septum.

The whole septum

When the deviation runs through the L-strut, the septum is taken out, rebuilt on the bench and put back. Against in situ correction in 169 matched patients, extracorporeal septoplasty gave comparable appearance results and better breathing: no patient in that arm had persistent obstruction, against 5 of 78 patients, 6.4 percent, in the in situ arm, who needed revision septoplasty. Mean operating times were 135 and 128 minutes.

Rests on: Lee and Jang · Gubisch · and extracorporeal septoplasty.

A nose already operated on

After augmentation rhinoplasty an implant can hide the bony asymmetry underneath. In 15 women with deviation after augmentation and asymmetry confirmed on computed tomography, 14 had developmental keystone asymmetry, revision used paramedian osteotomy with an extended spreader graft on the concave side, and 13 of 15 were judged successful at a mean 11.2 months.

Rests on: Lee et al., bony asymmetry after augmentation · Kienstra, revising the crooked nose · and revision rhinoplasty.

What to ask about a crooked nose correction

Questions the evidence supports asking.

How straight will it be, and how straight is your face

Ask the surgeon to point out the asymmetries of your midface and chin on your own photographs before any nose plan is drawn. Ask what target angle is realistic and how it is measured.

Rests on: Kosins et al. · Scott and Pearlman.

Will my septum be corrected in place or rebuilt

Both are standard. The in place route is shorter and keeps the framework; the rebuild is used for deviation running through the L-strut and has the better published breathing result in the one matched comparison.

Rests on: Lee and Jang · Tremp et al..

What holds the correction after the swelling goes

Ask which grafts or flaps are being used to keep the middle third straight. Nothing else in this operation has randomised evidence behind it: the spreader flap plus spreader graft combination does.

Rests on: Barone et al. · Gimeno-Torres et al. · and the journal archive on the septum and airway.

Will the bone work bruise me more

Piezoelectric instruments cut bone without cutting soft tissue. A meta-analysis of 10 studies and 554 patients found less swelling, less bruising, less pain and lower odds of mucosal injury than with conventional osteotomes, with no difference in operating time, on low-quality evidence.

Rests on: Khajuria et al., meta-analysis · and recovery.

What happens if it comes back

Recurrence is reported and it is treated as a surgical problem. Nocini followed 360 patients operated on for moderate to severe deviation by one surgeon, measured them on a nasal grid at a minimum of 24 months, and found the correction held, with one partial recurrence that was revised successfully. One further report describes a patient whose nasal axis deviation went from 7.3 degrees to 3.1 degrees on a course of facial exercise after recurrent septal deviation, which is a single case and not a treatment.

Rests on: Nocini, long-term outcomes on a nasal grid · Esme et al., recurrent deviation · Kienstra.

The terms, defined

The words used about a crooked nose.

• Deviated nose: a nose whose long axis leaves the midline of the face on the front view. [27494580]
• I-shaped deviation: the whole nose displaced straight to one side. [36826521]
• C-shaped deviation: the nose curved to one side and back, in a single arc. [36826521]
• S-shaped deviation: two opposing curves along the length of the nose. [36826521]
• L-strut: the L of septal cartilage left along the dorsum and the caudal edge after septoplasty, which holds the shape of the nose up. [36826521]
• Extracorporeal septoplasty: removing the whole septum, rebuilding it outside the nose and replanting it. [17131265]
• Osteotomy: a controlled cut in the nasal bone that lets it be repositioned. [36448013]
• Spreader graft: a strip of cartilage set between the septum and the upper lateral cartilage, used here to hold the middle third straight. [41265885]
• Spreader flap: the upper lateral cartilage folded in on itself to do the same job without a separate graft. [30868305]
• Bone-cartilaginous unit: a graft of septal bone still attached to its cartilage, used to brace a deviated septum. [37083441]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It covers what should be assessed and documented when breathing and shape are both in question.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries three chapters on the deviated nose and the septum behind it. They are written for surgeons.

• How to Manage Deviated Nose: Personal Tips
• Algorithm for treatment of anterior septal deviations
• Treatment of the Caudal Septum

The reference summary

Septoplasty in StatPearls gives the surgical detail. The National Library of Medicine also carries two plain patient chapters, an overview of the deviated septum and what surgery for it involves, in full text at no charge.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory.

The trials in progress

Correction of the deviated septum is under test in registered trials, so the evidence base moves.

• Cartilaginous Batten Graft Septoplasty in Caudal Septal Deviation, completed, 20 participants.
• Suture-based, Minimally Invasive Technique Used to Correct NSD, terminated, 4 participants.

What is not settled

• Recurrence rate is the number patients most want and the literature reports least. The large long-term figures come from single-surgeon series, one of them from the surgeon who developed the technique it describes. [17131265] [40361940]
• One randomised study supports the spreader flap with a spreader graft. Every other component of the correction rests on cohorts and single-surgeon series. [30868305] [41265885]
• Preservation techniques are being applied to deviated noses faster than outcome data is being collected on them. [33220837] [36729920] [37063499]
• Whether the correction should aim at the nose alone or at the asymmetric face beneath it is argued and not tested. [38833613] [27494580]
• Dorsal preservation can create a deviation in a nose that was straight before surgery, and the suture fixes described for it are reported by their authors in small series. [33399951]
• Grafts cut as a bone and cartilage unit are reported in 28 patients at one centre and have not been compared with a cartilage graft. [37083441]